A COMPREHENSIVE CASE ANALYSIS OF A
PATIENT REFERRED TO PHYSICAL THERAPY
USING AN EVIDENCE BASED APPROACH
JEFF ROBINSON, PT, FAAOMPT
Purpose of Presentation
 Primary purpose:
 To present a clinical case supported by the best available
evidence using guidelines set forth in The Guide to Physical
Therapist Practice1 (The Guide).
 Secondary purpose:
 To educate the reader about how to practice using evidence to
answer clinical questions .
 To summarize evidence based principles and concepts learned
by the presenter in pursuit of his doctorate in physical therapy.
 To accomplish the secondary goals, the author defines some
evidence based principles and concepts and shares with the
reader the clinical questions asked in gathering the evidence
for this work.
Patient/Client Management
 The Guide to Physical Therapist Practice1 recommends
categorizing the elements of patient/client management
into 5 categories.
 This paper will be divided up into sections corresponding
to each category of patient/client management.
 In each section, the data and evidence will be presented
corresponding to each category of patient/client
management.
 The various thought processes, clinical questions, and
clinical analysis will be described throughout the
presentation.
Patient/Client Management
 According to The Guide1 , the 5 Elements of
Patient/Client Management:

1. Examination – includes
History
 Systems Review
 Tests and Measures





2.
3.
4.
5.
Evaluation
Diagnosis
Prognosis
Intervention – includes
Coordination, communication, and documentation
 Patient/client-related instruction
 Procedural interventions

Examination – History
Identification
Information
Name – Ms. H
Address - USA
Date of Birth – 62 y/0
Sex – Female
Handedness: Right handed
Type of Insurance –
Private Aetna
7.
Race – White
8.
Ethnicity – Not Hispanic or
Latino
9.
Language – English
10. Education – Graduate
school/advanced degree
1.
2.
3.
4.
5.
6.
Social History
11. Cultural/Religious – no
12.
13.
14.
15.
issues that would affect care
With Whom Does Patient
Live? -Lives alone
Advance Directive – Don’t
know
Referred by: Neurosurgeon
Employment – full time
manager works outside of
home
Examination – History
 Living Environment
16. Lives in apt. with elevator
17. No assistive device for walking/mobilizing
18. Lives in private apt.
19. General health Fair to Good with no lifestyle changes in past
yr.
20. Social habits –non smoking, 2-3 glasses of wine per week, no
formal exercise, but used to walk to work
21. Family history – unknown
22. Medical / Surgical history – Hypertension, depression,
psoriatic arthritis, kidney disease, asthma. No significant
symptoms in past year except for back pain. No surgeries.
No female related problems
Examination - History
23. Current
Conditions/Chief
complaints:
a. Intermittent centralized
low back pain, but right
greater than left described
as deep and achy. Also
complains of bilateral
lower extremity pain can
be posterior or anterior or
both.
b. When did problem
begin? Came on gradually
in August 2009
c. What happened? There
was no specific incident
– gradually worsened
over time
d. Have you ever had the
problem(s) before? Yes,
but not to this degree.
Had a bout of low back
pain 10 years ago which
was isolated to low back
– had PT for 6 months
which helped.
Examination - History
Current Conditions/Chief
complaints continued:
e. Taking care of problem now
by avoiding aggravating
activities. Tried PT elsewhere
without help.
f. Sitting, lying down make
pain better *
g. Walking for 10 mins.,**
standing for 20 mins., and
lifting make problem worse.
h. Goal for PT is to be able to
walk to/from work without
23. .
pain (20 mins.) Be able to
go to antique shows and
walk around for the day
without pain
i. Currently not seeing anyone
else for this problem other
than MD who referred
patient. Sees a
rheumatologist regularly.
Seeing psychiatrist for
depression.
Examination - History
 Portney and Watkins detail how to convert pretest
probability to post-test probability:

1. Convert pretest probability to pretest odds:
Pretest odds = pretest probability /1-pretest probability
 Pretest odds = .472/1-.472 = .472/.528 = .89


2. Multiply the pretest odds by the LR to get post – test odds:
Posttest odds = pretest odds * LR
 Posttest odds = .89 * 6.6 = 5.874


3. Convert posttest odds to posttest probability:
Posttest probability = posttest odds/posttest odds +1
 Posttest probability = 5.874 / 6.874 = 85%

 Post-test probability has risen to 85%
Examination - History
24. Functional
work
Status/Activity Level:
25. Medications –
a. Difficulty with
Currently taking
Locomotion/movement prescription meds:
- 1. Difficulty with gait
 a. Enbrel b. celebrex c.
on all surfaces (pain
Prempro d. Cozaar e.
with walking)
Lexapro f. symbicort
b. No difficulty with self
 Non-prescription
care
medications – fish oil,
c. Difficulty with getting
calcium
groceries as she
26. Other Clinical Tests –
normally walks to store. MRI within past year
d. No difficulty once at
Examination - Systems Review
 Cardiovascular system:
white skin, good skin
On BP meds. Impaired,
integrity (despite having
but stable.
psoriatic arthritis)
 BP: 126/84
 Musculoskeletal
 Edema: non noted
System: Gross Range of
 HR: 78
motion and gross strength
 RR: not taken
– not grossly impaired but
will have to do more
 Integumentary System: detailed exam. Gross
symmetry – not grossly
not impaired. Integrity
impaired.
Normal pliability, no
presence of scar formation,  Height 5’6” Weight 130#
Examination - Systems Review
 Neuromuscular:


Gross Coordinated Movements:
Not impaired grossly. Gait,
Locomotion, Transfers,
Transitions not grossly
impaired, but is impaired from
functional limitation, disability
standpoint
Motor Function: Not impaired
grossly, but will need more
detail evaluation in
test/measures.
Cognition, Learning Style:






Communication: not impaired
Orientation X 3: not impaired
Emotional/behavioral
responses: not impaired
Learning barriers: none
Education needs: disease
process, use of
devices/equipment, ADLs,
exercise program
How does patient/client best
learn? Pictures and
Demonstration
 Communication, Affect,
Examination
 From the information gathered during the history
and systems review, my primary hypothesis was that
the patient appeared to be suffering from classic
lumbar spinal stenosis, however the prescription
from the MD read “spondylolisthesis”
Spondylolisthesis
 Definition – “slipping of one vertebra relative to an
adjacent vertebra.”
 5 types of spondylolisthesis:






Dysplastic – refers to the orientation of the facet joints allowing
anterior translation of vertebra
Isthmic – involves a lesion of the pars interarticularis
Traumatic – due to fracture of the posterior elements other than the
pars interarticluris
Pathologic – due to a tumor which affects the pars and allows
anterior translation
Degenerative – secondary to osteoarthritis leading to facet
incompetence and disc degeneration. This eventually leads to one
vertebra slipping forward on another.
Any of these conditions can result in lumbar spinal stenosis
Lumbar spinal stenosis
 Acquired (or degenerative) Lumbar spinal stenosis
is caused by the degenerative cascade of loss of disc
height, with bulging of the disc and infolding of the
ligamentum flavum.
 Facet joint degeneration follows which can lead to
hypertrophy and osteophytes.
 Spondylolisthesis can then result, but does not
occur in all patients.
 The combination of all of these factors leads to
lumbar spinal stenosis.
Examination
Tests and Measures
 According to the Guide1, tests and measures are used
“to help identify and characterize signs and
symptoms of pathology/pathophysiology,
impairments, functional limitations, disabilities.”
Examination
Tests and Measures – Posture & Pain
 Pain –Numeric pain rating scale (NPRS )
 Pain rated at a 5 on average when she gets it. Can be as low as
0 if in an easing position.
 Posture - Observational analysis:
 The patient stands with a very erect posture, lumbar spine
flattened, slight external rotation of bilateral lower extremities,
bilateral knees extended.
Examination
Tests and Measures - Gait
 Observational analysis: The patient ambulated with
a very erect posture, decreased thoracic and trunk
rotation, decreased bilateral arm swing, slight
external rotation of bilateral lower extremities, and a
narrow base of support.
Examination
Tests and Measures - Gait
 Walking capacity (time walked before the onset of
symptoms)

The treadmill test described by Deen et al8
- done in the clinic
- measure duration of timed walked on treadmill before
symptoms

The self paced walking test (SPWT) in a study by Tomkins et
al9
done outside of the clinic
 measured distance walked before onset of symptoms

Examination – Tests and Measures
Range of Motion
 Lumbar range of motion:
 Lumbar flexion: WNL
 Lumbar extension: limited to 10 degrees with pain in
low back and into buttock on right
 Lumbar right and left sidebending: limited to 15
degrees with pain especially right sided
 Lumbar/ thoracic rotation: Limited to 15 degrees
bilaterally
Examination – Tests and Measures
Range of Motion
 Inclinometer:
 Conflicting evidence regarding the reliability of inclinometers
Hunt et al and Chen et al found inadequate reliability for these
measuring instruments
 Ng et al and Saur et al found adequate reliability
 Ng et al did use a custom made device to eliminate pelvic motion

 Electrogoniometer
 2 relatively recent studies determined reliability of a flexible
electrogoniometer to be .89 and .96 for lumbar spine range of
motion.
 Validity was determined with excellent correlation to
radiographs.
Examination – Tests and Measures
Range of Motion
 Hip range of motion (tested supine)Flexion: Left 115
right 95. Internal rotation: Left 25 degrees right 10
degrees. External rotation: Left 45 degrees right 35
degrees. Extension (prone) Left 10 degrees right 0
degrees.
Examination – Tests and Measures
Range of Motion
 Muscle length:
 Thomas test + right and left – lacks 20 degrees from neutral on
right, left -15 degrees. Knee flexion angle 60 degrees.
 SLR negative for right and left (to 70 degrees before
complaints of tightness
Examination
Tests and Measures – Cranial and Peripheral Nerve Integrity & Reflex
integrity
 Cranial and Peripheral Nerve Integrity:
 Segmental neuro exam
 motor, sensation all WNL
 Neurodynamic testing – SLR negative and negative for
reproduction of symptoms
 Reflex integrity
 Normal DTRs (deep tendon reflexes) KJ (knee jerk) and AJ
(ankle jerk)
Examination – Tests and Measures
Joint Integrity and Mobility
 Tested via PAMs (passive accessory motions)
 Patient found to be hypomobile throughout the
thoracic and lumbar spine
Examination – Tests and Measures
Joint Integrity and Mobility – Evidence on
reliability
 Two earlier reliability studies18,19 reviewed were in
agreement that segmental spinal palpation testing was
not reliable using 9-11 point scales (ICCs - .03-.37)
 A more recent study 20found good agreement between
tests in determining the least mobile and most mobile
segment, but poor correlation to actual movement when
compared to motion testing through MRI which led the
authors to question the validity of the test. The findings
of this study were suspect, as they used an instrument
(MRI) to measure the construct (motion) which was
incompatible with the construct they should have
measured (stiffness)
Examination – Tests and Measures
Joint Integrity and Mobility - Evidence
 A relatively recent study by Fritz et al21, knowing the
poor reliability studies, focused on the role of diagnostic
tests (in this case segmental motion testing) in classifying
patients for intervention
 When condensing the grading scale into hypomobility,
hypermobility and normal mobility and classifying a
patient as hypomobile when 1 lumbar segment was
judged to be hypomobile, there does appear to be good
predictive validity in determining what type of
intervention may be appropriate
 Found that manipulation is beneficial for these patients
Examination – Tests and Measures
Motor Function
 Motor Function – Observational analysis - poor
ability to contract (poor isolation) of transversus
abdominis
 There are more objective tests to measure
transversus abdominis contraction (quality, timing,
degree).


Pressure biofeedback
Rehabilitative Ultrasound Imaging (RUSI)
Examination – Tests and Measures
Motor Function and Muscle Performance
 Pressure biofeedback
 Von Garnier22 et al found poor inter-tester reliability when
using pressure biofeedback during the “prone test”
• Rehabilitative Ultrasound Imaging (RUSI)

Koppenhaver et al22 found good inter-tester reliability when
testing transversus abdominis and multifidus muscle function
using ultrasound
Examination – Differential Diagnosis
 Cycling test


Test first described by Dyck and Doyle24
 Case study
 Authors observed pain with upright postures (walking and
standing)
 Decreased pain while on bike with FLEXION postures
(patient had pain in extension while on bike)
 This was more of a postural test vs. an exertional test
Dong and Porter25 studied patients with neurogenic
claudication and vascular claudication
 Conclusions were that the test was not sensitive enough to
distinguish between neurogenic and vascular claudication
Examination
Tests and Measures – Gait – Differential diagnosis
 Two stage Treadmill Test26





This is a test of 3 components
 Time walked on level treadmill
 Time walked on incline treadmill
 Recovery time
The most important variables found were time to onset of symptoms
and time to recover. Total walking time was not an important
variable.
Using the most important variables mentioned above a LR of 14.5
was calculated – meaning that a patient with an early onset of
symptoms with level walking and with a prolonged recovery time has
a 14.5 times greater chance of stenosis than not
An ability to walk for a long period of time while inclined vs. flat had
a high specificity (92.3) for ruling in lumbar spinal stenosis
Overall specificity of 94.7 for the two stage treadmill test, as 18 of 19
patients were correctly identified as stenotic (MR/ CT used as gold
Examination
Tests and Measures – Ergonomics and Body Mechanics
 Observational analysis: Patient demonstrated poor
body mechanics while lifting. Patient maintained
knees in locked position and flexed from lumbar
spine (vs. bending knees and hips).
Self care and Home Management &
Work, Community, and Leisure Integration or Reintegration
 These areas were broadly evaluated with the
Modified Oswestry Disability Index

Initial score of 44%
 MCID (Minimally Clinically Important Difference)
was found to be 6.27
History – Diagnostic tests
 MRI Findings:

There are degenerative changes of all of the intervertebral discs, most
severe at the L5/S1 level where there is prominent narrowing of the
disc space. There is mild diffuse disc bulging at the L4/L5 and L5/S1
levels and minimal disc bulging at the L2/L3 and L3/L4 levels.
There is no focal disc herniation. At the L5/S1 level, there is severe
bilateral facet joint osteoarthropathy with related very mild
anterolisthesis and prominent ligamentum flavum hypertrophy.
These degenerative changes result in moderate to severe central
canal stenosis. There is very mild degeneration of the facet joint
throughout the remainder of the lumbar spine. No other focal area
of central canal stenosis is present. There is very mild encroachment
of the neural foramina throughout the mid and lower spine without
evidence of focal nerve root impingement.
History – Diagnostic tests
 MRI findings continued


The conus medullaris and cauda equina appear normal. No
intradural or extradural mass is present . There is no other
abnormality of alignment. There are prominent discogenic
degenerative changes of the bone marrow surrounding the L5/S1
interspace; otherwise, the vertebral bodies and paraspinal soft
tissues are unremarkable.
Conclusion: There is multilevel degenerative disc bulging,
spondylosis, and facet joint osteoarthropathy, as described above,
with very mild degenerative anterolisthesis at the L4/L5 level. These
degenerative changes result in moderate to sever central canal
stenosis at the L4/L5 level. There is also very mild multi-level
foraminal encroachment without evidence of focal nerve root
impingement. No focal disc herniation is present within the lumbar
spine.
Evaluation
 According to The Guide1, “physical therapists
perform evaluations (make clinical judgements
based on the data gathered from the examination.”
Evaluation
 History and Systems Review
Evaluation
 Tests and Measures
 Pain
 Gait
Evaluation
 Tests and Measures
 Lumbar range of motion
 Hip range of motion
 Muscle length
 Neurological testing
Evaluation
 Tests and Measures
 Joint mobility testing
 Muscle function tests
Diagnosis
 My clinical impression of this patient is that she is suffering
from the pathology of lumbar spinal stenosis. A diagnosis
based on pathology is not always clinically relevant and
physical therapists must identify impairments, functional
limitations, and disabilities in order to appropriately manage
a patient.
 According to The Guide1, “although physicians typically use
labels that identify disease, disorder, or condition at the level
of cell, tissue, organ or system, physical therapists use labels
that identify the impact of a condition on function at the level
of the system (especially the movement system) and at the
level of the whole person. “
 I have created a list which is detailed in the following slides to
assist in visualizing the patient’s pathology, impairments,
functional limitations, and disabilities
Diagnosis - pathology
 Spondylolisthesis
 Lumbar spinal stenosis
 Asthma
 Depression
 Hypertension
 Psoriatic arthritis
Diagnosis - Impairment list
 Impairments:
 Decreased posture
 Pain rated at 5/10 on
average
 Decreased gait
Gait quality
 Gait distance without pain


Decreased range of motion
Lumbar
 Hip
 Muscle length in lower

extremities (hip flexors,
rectus femoris)


Decrease joint mobility
Decreased knowledge of
exertional parameters
Diagnosis –
Functional limitations and Disability lists
 Functional limitations:
 Inability to ambulate to / from work without pain
(this is a 20 min. walk and pain comes on at 10 mins.
 Inability to stand for greater than 10 mins.
 Disability:
 Inability to participate in “antiquing” trips (all day events that
entail standing, walking, mulling about)
 Travel is curtailed or at the very least made less enjoyable
Diagnosis
 Primary Practice Pattern –

4F Impaired Joint Mobility, Motor Function, Muscle Performance,
Range of Motion, and Reflex Integrity Associated With Spinal
Disorders
 Secondary Practice Pattern –

6A Primary Prevention/Risk Reduction for
Cardiovascular/pulmonary disorders
Prognosis




Study by Amundsen28 revealed in patients with non-surgical
treatment a good result was obtained by 70% of subjects. The
same study reported a good result from surgery for 79% of the
subjects. Subjects were assigned to a surgical group if their
condition was considered severe and a non-surgical group if
symptoms were moderate. Patients were followed for 10 years.
Study by Herno29 in which patients had “moderate” stenosis
concluded non-surgical management was a reasonable option.
Study by Hurri30 found improvements in surgical and non
surgical cases
Athiviriam et al31 also found improvements in both surgical
and non-surgical groups
Prognosis
Surgical vs. Non-surgical options
 Conclusions:
 Generally for severe stenosis, patients will do well with
surgery.
 For mild/moderate stenosis, patients may do well with nonsurgical intervention.
 There is no harmful effect of patients undergoing conservative
measures first.
 Given the cost of surgery, risk of surgery, and the fact patients
do not worsen with conservative care, and the fact that clinical
symptoms do not always coincide with radiographic findings, a
trial of non-surgical care is warranted for patients with lumbar
spinal stenosis.
Prognosis Frustrations
 Most studies that compared surgical to non-surgical
care lumped all non-surgical care together
 The non-surgical care options were generally:
physical therapy
 back braces
 spinal manipulation
 Analgesics
 muscle relaxants
 anti-inflammatories
 epidurals

Prognosis Frustrations
 Most studies did not differentiate between stenosis
secondary to spondylolisthesis and stenosis for other
reasons, although lumbar spinal stenosis secondary to
spondylolisthesis was an accepted occurrence in the
degenerative cascade and an accepted reason for stenosis
 Physical therapy was not well defined in any study and so
we don’t know what physical therapy means




Does it mean manual therapy?
Does it mean therapeutic exercise?
Does it mean modalities?
Other?
Other prognostic factors
 Accessibility of resources: +
 Adherence to the intervention









program: +
Age: +
Caregiver Consistency or
expertise: Cognitive status: +
Comorbities: Concurrent medial surgical and
therapeutic interventions: Decline in functional
independence: Level of impairment: +
Level of physical function: +/Living environment: +
 Multisite or multisystem








involvement: Overall health status: +/Potential discharge
destination: +
Premorbid conditionsProbability of prolonged
impairment: Psychological or socioeconomic
factors: +/Psychomotor abilities: +
Social support: +/Stability of the condition: -
Prognosis – Clinical Decision
 The general consensus was for mild to moderate stenosis
there is a reasonable chance that the patient may
improve with conservative care.
 My question to myself was – does my patient have mild
to moderate stenosis? According to the MRI – my
patient has moderate to severe stenosis. In taking all
factors into consideration, using my best clinical
judgement, I concluded the patient had moderate
stenosis from a symptom point of view.
 She is a high functioning patient working in a managerial
position, who can perform all work and self care
functions including short functional walks, but her goal is
to function at a much higher level than she is currently.
Prognosis Statement
 Given the severity of pathology (moderate),
comorbities (many, but well controlled), motivation
of patient (high), and all other factors of the
examination, the patient has good potential for
avoiding surgery and meeting the stated goals in the
plan of care in 8-10 weeks.
Plan of Care
 1.) Through coordination, communication, and documentation, the
patient will experience 100% satisfaction with the coordination of care
with her other health care providers, coordination of submitting claims
with our support staff, and communication and documentation
requested by her health insurance company or other health care
providers throughout the course of her visits.
 2.) Through patient instruction and education, the patient will
demonstrate understanding of the anatomy behind lumbar spinal
stenosis, the proposed treatment, and the importance of a home
exercise program through verbalization with 100% accuracy.
 3. )Through patient instruction, the patient will understand appropriate
parameters for aerobic exercise and be able to implement without
verbal cues.
Plan of Care
 4.) Utilizing the procedural interventions of therapeutic
exercise and manual therapy, the patient will demonstrate
increased hip range of motion of 10 degrees for each
motion.
 5.) Utilizing the procedural interventions of therapeutic
exercise and manual therapy the patient will demonstrate no
pain with lumbar extension and sidebending.
 6.) Utilizing the procedural interventions of therapeutic
exercise and manual therapy, the patient will demonstrate the
ability to walk to and from work for 20 minutes without pain.
 7.) Utilizing the procedural interventions of therapeutic
exercise, manual therapy, and
Plan of Care
 functional training, the patient will be able to tolerate 1 full day
of “antiquing” without pain.
 8.) Utilizing the procedural interventions of therapeutic exercise,
manual therapy, and functional training , the patient will
demonstrate an improvement of 6 percentage points on the
modified Oswestry Disability Index.
 9.) Utilizing the procedural interventions of functional training,
the patient will demonstrate proper lifting technique without
verbal cues.
** The frequency and duration required to accomplish the
above goals is 2X week for 6 weeks** after which a reassessment will be done.**
Intervention
Coordination, communication, and documentation





Coordination with the patient and our administrative staff was
necessary in order for our staff to receive all necessary insurance
cards, prescriptions, and personal information in order to submit
claims to the insurance company
Coordination with the patient and our office was accomplished to
allow early morning appointment times so the patient did not have to
miss work
Coordination with colleagues was done to ensure the unweighting
unit would be available during the patient’s appointment times
Communication to the patient in the realm of expected outcomes
(patient will not be 100% cured) was made clear to the patient
Findings were documented and letters sent to referring physician
and patients rheumatologist (pt. had concurrent diagnosis of
psoriatic arthritis which was well controlled)
Intervention
Patient/client related instruction
 Patient was educated on the nature of her problem
using a spine model to demonstrate what lumbar
spinal stenosis is
 Patient was educated about proposed treatment
options and given the rationale behind them
 Patient was educated on the importance of her home
exercise program and to not rely solely on (2) 45
minute appointments per week to solve the problem
Intervention
Procedural Interventions
 Manual therapy combined with exercise is effective
in patients with lumbar spinal stenosis
 A 2006 study by Whitman et al32 as the highest
quality study in this category
 This study is very clinically relevant because it
looked at combining physical therapy interventions
as is done in clinical scenarios and was determined
to be the best available evidence
Intervention - Best available evidence
 Brief Summary of best available evidence32
 RCT
 Comparison of 2 groups
 Group 1 received manual physical therapy, exercise, and
unweighted treadmill walking (MPTExWG)
 Group 2 received lumbar flexion exercises, treadmill walking
program, and subtherapeutic ultrasound (FExWG)
 Primary outcome measure was perceived recovery, secondary
outcomes included oswestry, pain, satisfaction, and treadmill
test
Best available evidence - Results
 The
primary outcome measure was “perceived recovery”
which at 6 weeks with the MPTFExWG showed
significantly better perceived recovery.
 At
the longer term follow-ups (1 year and 24+ months)
although there was still significant improvement noted in
perceived recovery, there no longer was a difference
between the groups. (Confidence interval included a
negative.)
 Secondary
outcomes were disability, treadmill walking
test, pain, and satisfaction all of which showed greater
improvement in the MPTFExWG, although not
statistically significant. (Confidence interval included a
negative.)
Case Analysis - Intervention
 Procedural Interventions – manual therapy
techniques




Typically sessions would start with manual treatments to the
spine and progress to manual treatments distally.
Manual therapy to the spine largely consisted of posterior to
anterior pressures (PAs) to the thoracic spine and lumbar
spine and passive physiological intervertebral movements
(PPIVMs) mostly into rotation
Manual treatments progressed distally to include mobilization
of the hip joint in various directions.
Manual therapy intervention also included soft tissue
mobilization of the gluteal, piriformis, and hip flexor
musculature.
Interevention
Procedural interventions
Case Analysis - Intervention
Case Analysis - Intervention
 Procedural Interventions - Therapeutic exercise – in
clinic exercise
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The patient ambulated on the unweighting unit for 15-30 mins.
after receiving manual treatment
The amount of unloading varied between 30-40#
In general, the patient was able to tolerate longer and longer
periods of time on the treadmill with decreased amount of
unloading over the course of treatment (although there was
variability depending on activity levels of the patient during
that day and time of day of treatment)
Case Analysis - Intervention
Case Analysis - Intervention
 Procedural Interventions:
 Therapeutic exercise – home exercise program
The patient was instructed in knee to chest exercises (single and
double knee to chest) holding for 30 secs. 3 sets to be done twice
daily.
 The patient was also instructed in a flexion exercise to be used as a
means of symptom reduction in standing.
 The patient was instructed in piriformis, hip flexor and quadriceps
stretching to be performed for 30 secs holds for 3 sets
 The patient was instructed in a thoracic rotation exercise in
sidelying - 20 reps. each side.
 The patient was instructed in a lumbar stabilization program.
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Intervention
 Hip flexor stretching:
 I was able to locate a study 36 which looked at 45 subjects with
low back pain and hip flexor tightness as determined by a
positive Thomas test.
 The randomized the subjects into 2 groups and then had one
group stretch actively and one group stretch passively.
 After statistical analysis, there were no differences found
between the groups.
Case Analysis - Intervention
3.
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Procedural Interventions – therapeutic exercise
The patient was encouraged to initiate a stationary cycling
program as this has been shown to replicate the effects of
unloaded treadmill walking in a well designed RCT37
The patient did not have easy access to a stationary bike and
did not enjoy that activity, but did have free access to a public
pool as a city resident
o
The patient was encouraged to begin an aqua
jogging program to simulate the unloading effects
of the unweighting system in the clinic
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The patient enjoyed the water and was very diligent
in adhering to a 2x week schedule – this offered
pain relief and therefore was not a “tough sell”
Case Analysis - Intervention
 Procedural intervention – functional training in self
care
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The patient was instructed in proper sleeping position (pillow
under knees).
The patient was instructed in proper body mechanics and
proper lifting technique
Reassessment
 1. Pain – patient rated pain at a level of 3/10 on average
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during provocative activities
2. Lumbar range of motion increased to 25 degrees for
extension before the onset of pain, 30 degrees for
thoracic / lumbar rotation
3. Hip range of motion increased to 120 for flexion, 30
degrees for internal rotation, 10 degrees for extension.
4. Gait quality improved to entail increased thoracic
rotation.
5. Walking capacity improved to the point the patient
could walk for 20 mins. before the onset of pain
6. Oswestry improved to 34%.
Outcomes
 1.) The patient experience d 100% satisfaction with the coordination of
care with her other health care providers, coordination of submitting
claims with our support staff, and communication and documentation
requested by her health insurance company or other health care
providers throughout the course of her visits (patient subjective
response).
 2.) The patient demonstrated an understanding of the anatomy behind
lumbar spinal stenosis, the proposed treatment, and the importance of
a home exercise program through verbalization with 100% accuracy.
 3. ) The patient understood appropriate parameters for aerobic exercise
and was able to implement without verbal cues.
Outcomes
 4.) The patient exerienced a reduction in pain rated at a 3 on
the NRPS during provocative activities. The MCID of the NPRS
is 27 – the patient did achieve an important clinically meaningful
change
 5.) The patient will demonstrate increased hip range of motion
of over 10 degrees for each motion to 120 degrees for flexion, 30
degrees for internal rotation, and 10 degrees for extension.
 6.) The patient will demonstrated increased lumbar extension to
20 degrees for extension and 30 degrees for rotation, but still
experienced pain at end ranges.
Outcomes
 7.) The patient was able to walk to and from work for 20
minutes without pain.
 8.) The patient will be able to tolerate 1 full day of
“antiquing” without pain using techniques to pace
herself.
 9.) The patient demonstrated an improvement of 10
percentage points on the modified Oswestry Disability
Index. The MCID of this instrument is 6.27 The patient
exsperienced a meaningful clinical change. 1
 10.) The patient was able to demonstrate proper lifting
technique without verbal cues.
Summary
 This case was a good example of a patient with a medical
diagnosis (spondylolisthesis and spinal stenosis) referred to
physical therapy and the physical therapist identifying
impairments, functional limitations, and disabilities and then
directing intervention to affect those areas. Although I
recognized my deficiencies in documentation and utilizing
tests and measures with sound reliability, I generally was very
happy with the interventions I utilized in helping this patient.
I was aware of the research regarding intervention for patients
with lumbar spinal stenosis while treating this patient. The
combination of having the appropriate equipment and having
the expertise in delivering the manual therapy and exercise
components of the interventions was obviously of great
benefit.
Future needs for research related to lumbar
spinal stenosis
 More research comparing various non-surgical
methods to come up with the best non-surgical
methods of treatment or best combination of nonsurgical methods (epidurals, medications, physical
therapy) for patients with lumbar spinal stenosis
 Build upon the best available evidence that we do
have to determine how to best replicate the short
term positive effects of physical therapy intervention
for patients with lumbar spinal stenosis for the
longer term.
References
 For references, please refer to annotated
bibliography.